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O’Connor M, Barbero U, Kramer DB, Lee A, Hua A, Ismail T, McCarthy KP, Niederer S, Rinaldi CA, Markides V, Clarke JRD, Babu-Narayan S, Ho SY, Wong T. Anatomic, histologic, and mechanical features of the right atrium: implications for leadless atrial pacemaker implantation. Europace 2023; 25:euad235. [PMID: 37523771 PMCID: PMC10473833 DOI: 10.1093/europace/euad235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Leadless pacemakers (LPs) may mitigate the risk of lead failure and pocket infection related to conventional transvenous pacemakers. Atrial LPs are currently being investigated. However, the optimal and safest implant site is not known. OBJECTIVES We aimed to evaluate the right atrial (RA) anatomy and the adjacent structures using complementary analytic models [gross anatomy, cardiac magnetic resonance imaging (MRI), and computer simulation], to identify the optimal safest location to implant an atrial LP human. METHODS AND RESULTS Wall thickness and anatomic relationships of the RA were studied in 45 formalin-preserved human hearts. In vivo RA anatomy was assessed in 100 cardiac MRI scans. Finally, 3D collision modelling was undertaken assessing for mechanical device interaction. Three potential locations for an atrial LP were identified; the right atrial appendage (RAA) base, apex, and RA lateral wall. The RAA base had a wall thickness of 2.7 ± 1.6 mm, with a low incidence of collision in virtual implants. The anteromedial recess of the RAA apex had a wall thickness of only 1.3 ± 0.4 mm and minimal interaction in the collision modelling. The RA lateral wall thickness was 2.6 ± 0.9 mm but is in close proximity to the phrenic nerve and sinoatrial artery. CONCLUSIONS Based on anatomical review and 3D modelling, the best compromise for an atrial LP implantation may be the RAA base (low incidence of collision, relatively thick myocardial tissue, and without proximity to relevant epicardial structures); the anteromedial recess of the RAA apex and lateral wall are alternate sites. The mid-RAA, RA/superior vena cava junction, and septum appear to be sub-optimal fixation locations.
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Affiliation(s)
- Matthew O’Connor
- Department of Electrophysiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK
- Department of Electrophysiology, Auckland City Hospital, Auckland, New Zealand
| | - Umberto Barbero
- Cardiac Morphology Unit, Royal Brompton Hospital, London, UK
- Cardiology Unit, Santissima Annunziata Hospital, Savigliano ASL CN1, Italy
| | - Daniel B Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Angela Lee
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Alina Hua
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Tevfik Ismail
- Department of Cardiology, Guy’s and St Thomas’ Hospital Guy's and St Thomas’ NHS Foundation Trust, London, UK
- Department of Cardiology, Kings College Hospital, London SE5 9RS, UK
| | - Karen P McCarthy
- Cardiology Unit, Santissima Annunziata Hospital, Savigliano ASL CN1, Italy
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | | | - Vias Markides
- Department of Electrophysiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK
| | - John-Ross D Clarke
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sonya Babu-Narayan
- Department of Electrophysiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK
| | - Siew Yen Ho
- Cardiac Morphology Unit, Royal Brompton Hospital, London, UK
| | - Tom Wong
- Department of Electrophysiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK
- Department of Cardiology, Kings College Hospital, London SE5 9RS, UK
- Department of Cardiology, National Heart & Lung Institute, Imperial College London, London SW3 6LY, UK
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Bock M, O’Connor M, Chouchane A, Schmidt P, Schaarschmidt C, Knoll K, Bahlke F, Englert F, Storz T, Kottmaier M, Trenkwalder T, Reents T, Bourier F, Telishevska M, Lengauer S, Hessling G, Deisenhofer I, Kolb C, Lennerz C. Cardiologist-Directed Sedation Management in Patients Undergoing Transvenous Lead Extraction: A Single-Centre Retrospective Analysis. J Clin Med 2023; 12:4900. [PMID: 37568301 PMCID: PMC10420171 DOI: 10.3390/jcm12154900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/07/2023] [Accepted: 07/18/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND The demand for transvenous lead extraction (TLE) has increased. In line with this, the safety of such procedures has also increased. Traditionally, TLE is performed under resource-intensive general anaesthesia. This study aims to evaluate the safety and outcomes of Cardiologist-lead deep sedation for TLE. METHODS We retrospectively analysed 328 TLE procedures performed under deep sedation from 2016 to 2019. TLE procedures were performed by experienced electrophysiologists. Sedation was administered by a specifically trained cardiologist (bolus midazolam/fentanyl and propofol infusion). Procedural sedation data including blood pressure, medication administration and sedation time were collected. Complications related to sedation and the operative component of the procedure were analysed retrospectively. RESULTS The sedation-associated complication rate during TLE was 22.0%. The most common complication (75% of complications) was hypotension requiring noradrenaline, followed by bradycardia requiring atropine (13% of complications). Additionally, the unplanned presence of an anaesthesiologist was needed in one case (0.3%). Deep sedation was achieved with midazolam (mean dose 42.9 ± 26.5 µg/kg), fentanyl (mean dose 0.4 ± 0.6 µg/kg) and propofol (mean dose 3.5 ± 1.2 mg/kg/h). There was no difference in medication dosage between those with a sedation-associated complication and those without. Sedation-associated complications appeared significantly more in patients with reduced LVEF (p = 0.01), renal impairment (p = 0.01) and a higher American Society of Anaesthesiologists (ASA) class (p = 0.01). CONCLUSION Deep sedation for TLE can be safely performed by a specifically trained cardiologist, with a transition to general anaesthesia required in only 0.3% of cases. We continue to recommend the on-call availability of an anaesthesiologist and cardiac surgeon in case of major complications.
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Affiliation(s)
- Matthias Bock
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
- DZHK (German Centre for Cardiovascular Research, Partner Site Munich, Heart Alliance), 80336 Munich, Germany
| | - Matthew O’Connor
- Auckland City Hospital, Department of Cardiology, Auckland 1023, New Zealand
| | - Amir Chouchane
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Philip Schmidt
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Claudia Schaarschmidt
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Katharina Knoll
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
- DZHK (German Centre for Cardiovascular Research, Partner Site Munich, Heart Alliance), 80336 Munich, Germany
| | - Fabian Bahlke
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Florian Englert
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Theresa Storz
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Marc Kottmaier
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Teresa Trenkwalder
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Tilko Reents
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Felix Bourier
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Marta Telishevska
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Sarah Lengauer
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Gabriele Hessling
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Isabel Deisenhofer
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Christof Kolb
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
| | - Carsten Lennerz
- German Heart Centre Munich, Department of Electrophysiology, Technical University of Munich, 80636 Munich, Germany (C.K.)
- DZHK (German Centre for Cardiovascular Research, Partner Site Munich, Heart Alliance), 80336 Munich, Germany
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Palmisano P, Ziacchi M, Angeletti A, Guerra F, Forleo GB, Bertini M, Notarstefano P, Accogli M, Lavalle C, Bisignani G, Landolina M, Zanotto G, D’Onofrio A, Ricci RP, De Ponti R, Boriani G. The Practice of Deep Sedation in Electrophysiology and Cardiac Pacing Laboratories: Results of an Italian Survey Promoted by the AIAC (Italian Association of Arrhythmology and Cardiac Pacing). J Clin Med 2021; 10:jcm10215035. [PMID: 34768557 PMCID: PMC8584354 DOI: 10.3390/jcm10215035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/23/2021] [Accepted: 10/26/2021] [Indexed: 01/23/2023] Open
Abstract
The aim of this survey, which was open to all Italian cardiologists involved in arrhythmia, was to assess common practice regarding sedation and analgesia in interventional electrophysiology procedures in Italy. The survey consisted of 28 questions regarding the approach to sedation used for elective direct-current cardioversion (DCC), subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation, atrial fibrillation (AF) ablation, ventricular tachycardia (VT) ablation, and transvenous lead extraction procedures. A total of 105 cardiologists from 92 Italian centres took part in the survey. The rate of centres where DCC, S-ICD implantation, AF ablation, VT ablation and lead extraction procedures were performed without anaesthesiologic assistance was 60.9%, 23.6%, 51.2%, 37.3%, and 66.7%, respectively. When these procedures were performed without anaesthesiologic assistance, the drugs (in addition to local anaesthetics) commonly administered were benzodiazepines (from 64.3% to 79.6%), opioids (from 74.4% to 88.1%), and general anaesthetics (from 7.1% to 30.4%). Twenty-three (21.9%) of the 105 cardiologists declared that they routinely administered propofol, without the supervision of an anaesthesiologist, in at least one of the above-mentioned procedures. In current Italian clinical practice, there is a lack of uniformity in the sedation/analgesia approach used in interventional electrophysiology procedures.
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Affiliation(s)
- Pietro Palmisano
- Cardiology Unit, “Card. G. Panico” Hospital, 73039 Tricase, Italy;
- Correspondence:
| | - Matteo Ziacchi
- Institute of Cardiology, S. Orsola-Malpighi University Hospital, University of Bologna, 40138 Bologna, Italy; (M.Z.); (A.A.)
| | - Andrea Angeletti
- Institute of Cardiology, S. Orsola-Malpighi University Hospital, University of Bologna, 40138 Bologna, Italy; (M.Z.); (A.A.)
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital Umberto I-Lancisi-Salesi, 60126 Ancona, Italy;
| | | | - Matteo Bertini
- Cardiology Unit, Azienda Ospedaliero-Universitaria Di Ferrara “Arcispedale S. Anna”, 44124 Cona, Ferrara, Italy;
| | | | - Michele Accogli
- Cardiology Unit, “Card. G. Panico” Hospital, 73039 Tricase, Italy;
| | - Carlo Lavalle
- Department of Cardiology, Policlinico Universitario Umberto I, 00161 Roma, Italy;
| | - Giovanni Bisignani
- Cardiology Division, Castrovillari Hospital, ASP Cosenza, 87012 Castrovillari, Italy;
| | | | - Gabriele Zanotto
- Department of Cardiology, Mater Salutis Hospital, 37045 Legnago, Verona, Italy;
| | - Antonio D’Onofrio
- Departmental Unit of Electrophysiology, Evaluation and Treatment of Arrhythmias, Monaldi Hospital, 80131 Naples, Italy;
| | | | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale Di Circolo-University of Insubria, 21100 Varese, Italy;
| | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, Cardiology Division, University of Modena and Reggio Emilia, Policlinico Di Modena, 41121 Modena, Italy;
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Kraft M, Büscher A, Wiedmann F, L’hoste Y, Haefeli WE, Frey N, Katus HA, Schmidt C. Current Drug Treatment Strategies for Atrial Fibrillation and TASK-1 Inhibition as an Emerging Novel Therapy Option. Front Pharmacol 2021; 12:638445. [PMID: 33897427 PMCID: PMC8058608 DOI: 10.3389/fphar.2021.638445] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 01/21/2021] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia with a prevalence of up to 4% and an upwards trend due to demographic changes. It is associated with an increase in mortality and stroke incidences. While stroke risk can be significantly reduced through anticoagulant therapy, adequate treatment of other AF related symptoms remains an unmet medical need in many cases. Two main treatment strategies are available: rate control that modulates ventricular heart rate and prevents tachymyopathy as well as rhythm control that aims to restore and sustain sinus rhythm. Rate control can be achieved through drugs or ablation of the atrioventricular node, rendering the patient pacemaker-dependent. For rhythm control electrical cardioversion and pharmacological cardioversion can be used. While electrical cardioversion requires fasting and sedation of the patient, antiarrhythmic drugs have other limitations. Most antiarrhythmic drugs carry a risk for pro-arrhythmic effects and are contraindicated in patients with structural heart diseases. Furthermore, catheter ablation of pulmonary veins can be performed with its risk of intraprocedural complications and varying success. In recent years TASK-1 has been introduced as a new target for AF therapy. Upregulation of TASK-1 in AF patients contributes to prolongation of the action potential duration. In a porcine model of AF, TASK-1 inhibition by gene therapy or pharmacological compounds induced cardioversion to sinus rhythm. The DOxapram Conversion TO Sinus rhythm (DOCTOS)-Trial will reveal whether doxapram, a potent TASK-1 inhibitor, can be used for acute cardioversion of persistent and paroxysmal AF in patients, potentially leading to a new treatment option for AF.
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Affiliation(s)
- Manuel Kraft
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
- HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Antonius Büscher
- Clinic for Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Felix Wiedmann
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
- HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Yannick L’hoste
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
- HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Walter E. Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
- HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Hugo A. Katus
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
- HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
| | - Constanze Schmidt
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
- HCR, Heidelberg Center for Heart Rhythm Disorders, University of Heidelberg, Heidelberg, Germany
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